Tuesday, August 17, 2010

Nutrition for Pregnancy

Nutrition For Pregnancy:

Food First
By
Darcey Blue French

Clinical Nutrition
NAIMH
April 25, 2008

Pregnancy is probably one of the most exciting and challenging times in a woman’s life, filled with questions, emotional ups and downs, and strange physical changes in a once familiar body. The resurgence in natural childbirth in recent times has increased the use of natural supplements, herbs and vitamins during pregnancy, as a way to remedy the discomforts and encourage a healthy pregnancy. During the course of my research I found that the information available on nutrition for pregnancy lies all over the map. To say the least it is very confusing. I can’t imagine newly pregnant women being able to make sense of all the recommendations that are different every where you look. What is safe, what is not? What is required for a healthy pregnancy, and infant, and what is beneficial but not necessary? To what degree should a woman rely on information from books about what is best to eat, and to what degree should she trust her intuition and inner guidance and her body’s instinctual knowledge about her needs during this sensitive time? My own frustration in uncovering the truth about what is healthy and what isn’t for a pregnant woman has led me down to one overriding truth about nutrition in pregnancy: eat a wide variety of whole foods, eat when hungry, avoid toxic substances, get plenty of fresh air, water, exercise, rest and emotional support.

Caloric Requirements in Pregnancy

Pregnancy is known as a time when women have strange cravings, and eat more. They are “eating for two.” It is true that the food a pregnant woman eats is the primary source of nutrition and fuel to continue to support her good health, and the growth of her unborn child, but she does not need to eat twice as much. A woman should gain weight during the course of her pregnancy, and that will require a greater intake of food. Overall a woman of normal body weight should gain between 25-35 lbs over the course of her pregnancy. (Sizer) It takes about 75,000 calories over the course of the 9 month gestation to build a baby. (Kahl) For most women this is somewhere between 300-500 extra calories per day. (Sizer) That certainly isn’t room for a free for all on food throughout the pregnancy. The caloric requirements in the first trimester remain about the same as a non-pregnant woman, but increase by about 300-500 calories per day in the second and third trimester, respectively. (Butte et. al) Even though caloric intake doesn’t increase by leaps and bounds, especially in the first trimester, nutrient requirements do. (Sizer) I will go into more detail about the requirements for each nutrient below; but suffice it to say that the foods consumed during pregnancy should, in general, be nutrient dense. I do not believe that any woman should restrict foods in her diet during pregnancy, barring allergy or potential toxins, but foods selected should have plenty of nutrients, and calories should be focused on the nutrient dense foods.

The requirements for protein, carbohydrate and fat in pregnancy are a bit controversial. Across the board there seemed to be either very little focus and information on precisely how much of each macronutrient a woman should eat, to very different recommendations in different sources. That leaves me with the general recommendation that a woman should eat from a wide variety of food sources, which include protein, carbohydrates and fats.

My conundrum is this; Paleolithic hunter gatherer women who were pregnant almost certainly didn’t eat 70 percent of their calories from grain carbohydrate. The foods they mostly likely were eating were protein rich wild meats and seafood, vitamin and mineral rich green plants and antioxidant rich fruits and berries. Fat was certainly prized, especially in winter when fresh plant foods were scarce. We can look to traditional Inuit diets, which are almost solely based on meat protein and fat for much of the year when the frozen north produces no plant foods. Those women certainly didn’t eat mountains of barley, quinoa or whole grain toast. Yet, they continued to have successful pregnancies. Most of the modern recommendations focus on eating plenty of carbohydrates from whole grain sources. This is not in and of itself a bad thing. Whole grains are healthy for many individuals, and they provide fiber, but grains aren’t a nutrient DENSE food like greens, fruits and meats. Not to mention they also contain phytates which can inhibit the absorption of mineral nutrients from other foods. Is a grain based diet the most sensible choice for a pregnant woman who needs more nutrients? Is a protein rich diet dangerous for a pregnant woman and her unborn child? What would provide the most nutrient rich diet for a pregnant woman?

Based on Paleolithic diets, I would conjecture that protein rich diets were the norm for pregnant women. I don’t believe they would have changed their diets dramatically during pregnancy, with the exceptions of removing any foods deemed taboo by their culture, and increasing quantity of food intake. They might have also had special foods which were taken prior to or during pregnancy. The Weston Price Foundation tells us that the Masai, a semi nomadic tribe in Africa who raise cattle, will feed both men and women getting ready to mate/marry milk from cattle fed on rich spring grass. This milk is richer in fat and fat soluble nutrients like vitamin D, vitamin A and vitamin K, than at any other time. (Bianco-Davis) In a sense, they are preparing the young people for the rigor of pregnancy and parenthood with special foods.

PROTEIN

Protein is one of the most essential macronutrients for a growing fetus and pregnant mother. The amino acids are the base upon which all tissues are formed including nucleotides for DNA and RNA in the cell, neurotransmitters, hormones and bone. Protein is also essential for building the mothers hormones, placenta and supporting production of red blood cells (Somer). Adequate protein in the diet can also improve labor performance; by increasing the strength of contractions and reducing stress on the mother and baby and improving the birth outcome. This is especially true in the final weeks of pregnancy (Sullivan).

Considering that in class we’ve learned that most women aren’t eating enough protein anyway, and a pregnant woman’s protein needs almost double in the last two trimesters of her pregnancy, I’d recommend approximately 90-100g of protein daily for a pregnant woman of normal BMI (Zimmerman). The DRI for protein is .8g/kg, and we’ve learned that that number is probably low for most women. According to the DRI recommendations a 130 lb woman would need approximately 46g grams of protein per day. In class we’ve recommended that women usually get around 1g/kg of protein. Thus, a 130 lb woman would then need 58.5g of protein per day. If we go with Zimmerman’s recommendation to double protein intake in the second and third trimester, a woman would need approximately 117 g of protein per day! According to another source, a woman should increase her protein intake by 25g or approximately 1.1g/kg. (Sizer) At .8g/kg a woman who is eating 46g of protein should increase it by 25g to 71g during her pregnancy. Of course these numbers increase for a woman of greater stature, and likewise decrease for a smaller woman. The range of 70-120g of protein per day is rather large, and so a nice mid range number lays somewhere around 90-100g. 100g of protein per day would be about 400 calories. In a 2500 calorie per day diet, this is about 16% of the daily calories from protein. This still seems a bit low as an overall intake by percentage. I would even consider recommending that 20-25% of the diet be from protein (Luke). In a 2500 calorie diet this would be about 600 calories from protein or 150g. Paleolithic diets contained anywhere from 20-35% protein, and this should be quite healthy and tolerable for a pregnant woman.

There is obvious wiggle room in the diet concerning protein, and larger intakes may be favored by some women. I would go so far as to say that a woman may eat protein freely, as long as she is continuing to eat enough carbohydrate (see discussion below) and isn’t eating too many calories. Protein often comes with fat, especially in meat or egg sources, and could tip the scales as far as calorie requirements go. As in all things the middle road is best. Enjoy some fatty meats, and some leaner meats, include eggs, and legumes as well.

To achieve this on daily basis a pregnant woman should consume approximately 25-30g of protein at each of three meals, in addition to protein rich snacks supplying another 15-25g. This is about 3-5 servings of protein per day. Good sources include wild fish, free range meats, poultry, eggs and legumes. 4oz of meat or chicken would supply between 25-30 g, 2 eggs approximately 12g, and 1 oz of almonds (23 kernels) approximately 6g or two tablespoons of nut butter 5g, and 1 cup of cooked beans approximately 14.5g.

A woman who chooses a vegetarian diet must be extremely conscious of getting enough protein from legumes, nuts, dairy products and eggs. To get 100mg of protein from legumes alone, a woman would need to eat between 6-7 cups. That’s a tall order to fill. The addition of 4 eggs a day would provide 24 g of protein. 1 cup of whole milk would provide close to 8 g, and cheese and yogurt will also provide comparable amounts. A mix of eggs, dairy products, and legumes could supply enough protein for a healthy vegetarian pregnancy as long as the mother is conscientious. 1 glasses of milk (8g), 1 oz cheese (6g), plus 4 eggs (24g), 1 c of almonds (30g) and 2 c of legumes (29g) would provide about 100g of protein. In addition she should be conscious of getting enough of the nutrients usually found in animal protein like iron, zinc, B-vitamins, vitamin D and Omega 3 fatty acids like DHA from supplements.

Based on the above dietary calculations I think it would be extremely difficult to maintain a healthy pregnancy on a vegan diet, but if this diet is unable to be modified for the duration of the pregnancy, supplemental B-12 and essential fatty acids like DHA MUST be supplemented. These are essential nutrients only found in animal foods that can greatly influence the health of the mother and infant. DHA is now available in vegetarian supplements of flax oil fortified with DHA from algae. She should also consider supplementing with iron, zinc, vitamin D and extra B complex vitamins (Somer). Lower protein intake in vegan diets might be acceptable if the mother is in good health, but she should still make a concentrated effort to favor protein rich foods to ensure adequate intake.

A recommended diet for a vegan woman in pregnancy would include:

7 servings vegetables

3 servings fruits

6-11 servings whole grains

4 servings legumes, nuts, seeds

4 servings of calcium rich foods

A source of supplemental B12, Iron, and DHA.

(Somer)

CARBOHYDRATE

Most books on pregnancy and most of the nutritional recommendations made for women, pregnant or not, suggest that carbohydrates from whole grains, fruits and vegetables should comprise the majority of the daily diet. None of the sources I consulted gave detailed reasons for carbohydrate to form the base of pregnancy diet. We do know that eating more than about 100 g of carbohydrate a day will prevent ketosis, the burning of ketones produced in the liver from fat and protein as fuel. There is some indication that ketosis may be associated with poor birth outcome (Jovanovic). Because of the lack of information proving the safety of a low carbohydrate diet that produces ketosis in the mother, I would not recommend anything below 100g of carbohydrate per day. The DRI for carbohydrates in pregnancy is 175g. This would prevent ketosis in the mother and supply enough carbohydrate to fuel the development of the fetal brain (Sizer). Based on this data a pregnant woman should eat a moderate amount of carbohydrates from whole food sources. The foods that supply carbohydrates, like whole grains, vegetables and fruits also supply fiber, which is important in preventing constipation during pregnancy. 250g of carbohydrate per day would supply about 1000 calories, and is about 40% of caloric intake for a 2500 calorie per day diet.

These carbohydrates should obviously come from whole food sources. White flour hamburger buns, sugar coated candies, and refined flour products like pasta and crackers and bagels are not good sources of carbohydrate. These foods lack any of the nutritional benefits that carbohydrates can supply, like fiber, and vitamins, minerals and antioxidants. Carbohydrates in the pregnant woman’s diet should come from the most nutrient dense sources possible. Leafy and dark greens, brightly colored vegetables like bell peppers and tomatoes, and nutrient rich starchy vegetables like sweet potatoes and winter squash are excellent choices. In addition brightly colored fruits and berries which are rich in antioxidants, vitamin C, and fiber should be included.

Whole grains and legumes may also be included as a source of carbohydrates. Brown rice, quinoa, amaranth, corn buckwheat, and legumes are all great sources of fiber, micronutrients and complex carbohydrates. But the caveat is that whole grains also contain phytates which can reduce absorption of minerals like iron, calcium, and zinc in the digestive tract, and are less nutrient dense than the vegetables and fruits. All whole grains should at a minimum be soaked prior to cooking and eating, and if possible sprouted to reduce the phytate content and improve the mineral absorption. A pregnant woman should feel free to eat these whole grains in moderation, but I suggest that most of her carbohydrate intake should come from the fruit and vegetable sources, because they are so rich in vitamins, minerals and antioxidants, and lower in calories. Essentially you get more bang for your calorie with these foods, and as stated above, nutrient requirements increase dramatically more than caloric requirements in pregnancy.

A woman who is concerned with fiber intake or is experiencing problems with constipation may choose to eat more grains, but should strive to consume 8-10 servings of vegetables and fruits per day. I would also recommend that pregnant woman avoid grains that contain gluten, especially if she has a sensitivity or allergy herself, or if gluten intolerance runs in her family. The possibility of affecting the fetus, which may be allergic to gluten through genetic inheritance, is a strong possibility. This isn’t to say a woman who has no problems with gluten should strictly avoid all gluten containing foods, but it is something to keep in mind.

A pregnant woman should also keep in mind that carbohydrates in excess could also contribute to excessive weight gain during her pregnancy. On the other hand a woman who is having trouble gaining enough weight may choose to eat more carbohydrate to boost her fat stores. Excessive carbohydrate intake could also contribute to gestational diabetes in a woman who is insulin resistant before becoming pregnant. In this case, carbohydrates can be reduced to between 175-200 g and sources should come from lower glycemic sources like vegetables and fiber rich fruits.

FAT

Fat is known as the big, bad nutrient, and is much maligned in the literature on pregnancy nutrition. Some go as far as to say there is no room for butter in the pregnant woman’s diet (Somer). Pregnant are women urged to keep their fat intake below 25-30% of their diet. In a 2500 calorie diet that is approximately 77g of fat per day, or 700 calories from fat. In my proposed pregnancy diet including 100g of protein, 250g of carbohydrate, 16% and 40% of caloric intake respectively, a woman would need to fill the rest of her calories with fat, at about 44% of her diet. Most dieticians would be aghast. They would suggest increasing the carbohydrate content of the diet by about 15%. But in my proposed diet a woman eating plenty of whole food protein from meat, fish, and eggs would naturally consume the fat contained within those foods. One source seems to agree with me about a higher fat content in the diet, suggesting a diet containing 40% fat, 40 % carbohydrate and 20% protein (Luke).

Fat, despite its reputation, is a very important part of our diet and especially important during pregnancy. Fat itself makes up 70% of the brain tissue and is absolutely vital to development of the fetal brain and vision (Somer). Fat and cholesterol are also important building blocks for hormones both in fetus and mother. Fat is also an important carrier for the fat soluble vitamins A, D, and E.

It is also important to note that the type of fat in the diet is possibly even more important that the content of fat in the diet. Transfats are essentially poison, while the essential fatty acids from Omega 3 oils, DHA, EPA and AA are vital for proper development in fetus and infants, and for the health of the mother during pregnancy. I will go into more detail about the essential fatty acids below. Fats during pregnancy should always come from whole food sources, be fresh (never rancid), and favor the healthy fats like Omega-3. Processed fats of all kinds, deep fried rancid oils and transfats in processed foods should be avoided. Fats from whole foods acceptable for pregnancy include butter, ghee, olive oil, coconut oil, flax, fish oils and a limited quantity of vegetable oil, as well as any fat naturally found in free range meat, poultry, eggs and fish.

FIBER

Fiber, though not truly a macronutrient that provides vital nutrients or building blocks for tissues, is still an important consideration in pregnancy. Fiber is very important in maintaining proper digestive functions, especially in pregnancy when nausea, constipation, and changes in appetite occur. Fiber is helpful in increasing stool bulk, speeding movement of waste through the digestive tract to prevent reabsorbtion of toxins, and help in preventing diverticulosis, IBS and hemorrhoids. It is well known that most Americans don’t eat enough fiber to begin with, let alone pregnant women. The DRI for fiber in pregnancy is 28g (Sizer). But true needs for fiber both in pregnancy and not are closer to 35-40g per day (Kahl). This should be easy to accomplish for a pregnant woman eating a whole food diet rich in fruits, vegetables, nuts, seeds and whole grains in moderation. 10 g of fiber at each of three meals, plus some fiber rich snacks should accomplish this goal. Women can easily add fiber to their diet by consuming ground flax, sesame or chia seeds on their food, or by taking a non stimulating fiber supplement based on seeds or acacia gum fiber. When purchasing a fiber supplement, the label should be checked carefully for any stimulant laxative herbs like senna, cascara sagrada/buckthorn, aloe vera or rhubarb. These laxative herbs may cause diarrhea or increase peristalsis which could possibly cause uterine contractions.

A pregnant woman who becomes constipated should look closely at her diet to ensure there is plenty of bulking fiber, abundant fresh water and fluids, that she is eating enough, and that any iron supplement she might be taking isn’t causing constipation. I have found that a simple tea of marshmallow, dandelion, burdock and yellow dock can help to resolve mild constipation in pregnancy without being over stimulating. Also adding more ground flax seed and water can help as well. 1 tbsp of ground flax seeds provides about 2g of fiber (USDA Nutrient Database). This can be stirred into fruit, salads, grains, soups or plain water.

Micronutrient Requirements in Pregnancy

As was stated above, though caloric requirements increase only somewhat during the last two trimesters of pregnancy, nutrient requirements increase dramatically beginning in the first weeks of pregnancy. Adequate nutrient intake both before and during pregnancy are of utmost importance for the proper development of the placenta, fetus, and in maintaining the mother’s good health. I will discuss the major nutrients below in detail, including good dietary sources for each. Some nutrients may be readily available from a whole food diet, and others may require moderate supplementation during pregnancy. Either way, a pregnant woman should choose the most nutrient dense foods available during her pregnancy as nutrients from food are almost always more readily absorbed and utilized, and safe.

ESSENTIAL FATTY ACIDS

Most people know the value of getting enough of the omega 3 essential fatty acids in their diet or through supplementation for a whole slew of health reasons, including cardiovascular health, reproductive health, skin and tissue health and cognitive/brain health. But the essential fatty acids play a special role for both mother and fetus during pregnancy. It’s hard to estimate exactly how much a woman should supplement with omega 3 fatty acids, because it will depend greatly on the kind of diet she eats. Is her meat free range and grass fed with a good fatty acid balance? Does she eat nuts and seeds? What kind of oil does she use to cook with? Did she take any supplemental omega 3 fatty acids before pregnancy to ensure her cells are replete? The balance of omega 3 and omega 6 fatty acids in a woman’s diet will influence how much extra omega 3 a woman should take. Omega 6 fatty acids are also considered an essential fatty acid and required for a healthy pregnancy, but most women get enough of these from nuts, seeds, and oils pressed from nuts and seeds, or their meat. The key is the balance between omega 3 and omega 6. Everyone, including pregnant women need to have a ratio of omega 6: omega 3 about 2:1 or 3:1, most American diets are close to 15:1 or 20:1, hence the need for supplementation with omega 3 oils found in fish. Many people will use flax oil as a source of omega 3 fatty acids, unfortunately the alpha linolenic acid (ALA) found in flax, is an omega 3, but is not directly used in the body. The human body requires DHA and EPA omega 3 fatty acids. ALA can be converted to DHA at a very small percentage, so using flax oil will probably not provide enough usable DHA omega 3 fatty acids for maintaining stores during pregnancy. The conversion rate of DHA from ALA increases in pregnant women, especially in the first 10 weeks, to ensure the fetus gets the DHA needed, but it isn’t enough to rely on this for the duration of the pregnancy as DHA levels have been shown to decrease in the last trimester (Otto). This leads us to the conclusion that most women should supplement with fish derived omega 3 fatty acids which contain DHA and EPA that needs no conversion in the body.

Recommendations are usually expressed as a range between 4-6g for a single birth (Zimmerman). But mothers of multiples should take up to 10g per day (Kahl). 2 grams of omega 3 fatty acids have been shown to help prevent premature delivery (Masterjohn).

Women with low EFA status are 8 times more likely to develop preeclampsia (Kahl).

Adequate omega-3 fatty acids in the mother’s cell tissue stores protect against gestational diabetes, preeclampsia, and post partum depression (Kahl). Platelets of preeclamptic women had a high ratio omega 6 to omega 3 compared to normotensive pregnant women, unfortunately, the western diet has a high ratio of omega 6 to omega 3 fatty acids which may contribute to platelet aggregation and vasoconstriction and gestational hypertension (Velzing-Aarts). Current dietary habits in the modern diet often lead to DHA depletion in the mothers endogenous stores by the end of the pregnancy (Hornstra). The developing fetus will draw on the mother’s stores of DHA if dietary intake is not adequate, leading to EFA depletion in the mother (Masterjohn). Regular supplementation of essential fatty acids can prevent mother’s stores from being depleted and help in prevention of post-partum depression.

The development of the fetus requires large amounts of DHA, for brain, vision and nervous system development during gestation (Kahl). Essential fatty acids are required for normal fetal and neonatal growth, neurological development and function, learning and behavior and intrauterine nutrition may influence adult risk for chronic diseases (Hornstra). Studies have shown that a daily dose of cod liver oil (rich in DHA and EPA omega 3 fatty acids) used in pregnancy and lactation increased IQ of children at age 4 (Masterjohn). Use of cod liver oil in pregnancy reduces risk of type 1 diabetes in the offspring by 70 % (Masterjohn). AA and DHA levels are correlated to birth weight, head circumference, abdominal circumference, and length of gestation (Velzing-Aarts).

So how should a woman get her daily 4-6 grams of essential fatty acids? A diet rich in grass-fed meat, and oily deep sea fish will go a very long way in providing plenty of omega 3 and omega 6 fatty acids in the proper ratio. In addition, the regular consumption of a tablespoon of cod liver oil or several tablespoons of fish oil (without vitamin A and D) will cover the daily requirements for the essential fatty acids.

4 oz wild salmon 822mg

3.5 oz canned salmon 693mg

1 can sardines 468 mg

1 tbsp cod liver oil, Nordic Naturals 3750 mg

CALCIUM

The AI (Adequate Intake) for Calcium in pregnancy is 1000 mg, and the upper tolerable limit is set at 2500 mg (Sizer). A woman should strive for 2-3g of calcium from all sources per day (Kahl). Calcium is a very important nutrient during pregnancy and must not be neglected. Calcium is used to build the bones of the growing fetus and maintain the mother’s bone stores (Somer). Approximately 200 mg of Calcium are deposited in the fetal skeleton per day (Prentice). Over the course of the entire pregnancy 30-40 grams are deposited in the fetal skeleton (Zimmerman). There is some concern about reduced maternal bone density in pregnancy with low calcium intakes. Though there have been few studies on maternal bone density with low calcium intake, a daily intake of 1300 mg of Calcium has been shown to prevent bone density loss (Prentice). If calcium intakes are not adequate to meet the needs of both mother and fetus, calcium stores can be mobilized from maternal bones and be deposited in the fetal skeleton (Zimmerman). In order to protect against possible bone loss in women, adequate calcium intake is of great importance. It is interesting to note that calcium absorption increases during pregnancy, which improves the chances that a woman will receive enough calcium from her diet (Prentice).

Increased calcium intake also protects against gestational hypertension, preeclampsia, and premature delivery (Prentice). Studies have shown that 1-2 g of supplemental calcium can prevent preeclampsia and hypertension in both mother and fetus (Prentice, Somer). Preeclampsia also seems to be more common in countries with low calcium intake (Prentice). Too much calcium could possibly result in kidney stones, increased risk of urinary tract infection and reduced absorption of other minerals (Prentice). So care should be taken not to exceed 2.5 grams per day between supplementation and dietary intake.

So what is the best way to ensure a woman is getting enough calcium during pregnancy? Dietary sources are going to be the most easily absorbed and utilized and a woman should consume 3 servings of calcium rich foods per day (Somer). These food sources will also contain a wide spectrum of other nutrients needed during pregnancy, and are less likely to cause complications of overdosing on calcium. The following foods supply 300mg of calcium in the quantity listed.

In addition to calcium rich foods a woman may choose to use a prenatal multivitamin supplement that contains calcium. Most of these contain 1000mg of calcium, and eating another 900-1000 mg per day would ensure more than enough calcium to be protective of bone health and preventative against hypertension and preeclampsia.

MAGNESIUM

The RDA and Tolerable Upper Intake for magnesium in pregnancy is 350 mg (Sizer). But the recommendations in other sources are closer to 400mg (Zimmerman). As we well know from our classes at NAIMH, most people are severely deficient in magnesium and are experiencing minor or major symptoms of magnesium deficiency. For most American women who become pregnant, I suspect magnesium deficiency is a problem, and in many cases 400 mg does not improve the symptoms. Larger doses are often used to replenish magnesium stores. Magnesium deficiency in pregnancy can specifically cause fatigue, increased muscle cramping, and hypertension and increase risk of premature birth (Zimmerman). Prolonged magnesium deficiency may also be related to occurrence of SIDS (sudden infant death syndrome) (Durlach). In addition magnesium is a key player in blood sugar regulation and insulin metabolism, muscle and nerve function, uterine relaxation and contraction in labor (Somer). Magnesium can also help prevent and alleviate late pregnancy constipation, and stress or sleep problems. Because magnesium is such a vital nutrient in the body, involved in over 300 body reactions, its importance during the sensitive time of pregnancy should not be underestimated.

Excessive magnesium intake, though often used safely in therapies in non pregnant women may be harmful to the fetus. The fetal kidney does not excrete Mg as efficiently as an adults, hypermagnesia may occur and could cause respiratory depression, poor suckling, hyporeflexia (low reflex response), and effect Ca metabolism, peripheral circulation or induce discharge of meconium (Durlach). That said, the usual recommendation to supplement with 600-800 mg of magnesium may not be entirely safe for the fetus, though magnesium deficiency is also definitely not safe for the fetus. A pregnant woman must strive to get plenty of magnesium rich foods in her diet, and consider supplementing with a small amount of magnesium as it occurs in a prenatal supplement, between 400-600mg.

Iron is one nutrient commonly supplemented in pregnancy due to increased needs during pregnancy and the difficulty in eating adequate amounts, despite increases in maternal iron absorption, up to 50% (Somer). The RDA for iron intake in pregnancy is 27 mg and the Tolerable Upper Limit is 45mg. Blood volume increases dramatically during pregnancy and iron is used to build maternal and fetal blood and increase fetal body weight (Zimmerman). 246 mg of iron is used to stockpile fetal tissues, 134 mg is found in the placenta, and 290 mg is used to increase maternal blood volume, that is approximately 2.4 mg a day during pregnancy, not counting the additional mg or more needed to support normal maternal body processes (Somer). Over the entire pregnancy that is about 1000mg of iron (Bothwell). That’s a lot of iron! Iron deficiency in pregnancy can lead to anemia, exhaustion, birth defects, low birth weight or premature birth (Zimmerman). Even women who start with enough iron at conception become depleted by the third trimester if not supplemented (Zimmerman).

Most women have difficulty consuming enough iron their diets, and so often use supplemental iron to make up the difference. One drawback to supplemental iron is the side effect of constipation, worsened by the natural tendency of the pregnant woman to become constipated in late pregnancy. If a woman is eating a protein rich whole food diet, is it possible to get enough iron from dietary sources? Were Paleolithic women becoming anemic in pregnancy from lack of iron? Does increasing iron absorption by using sources of heme (animal sourced) iron (absorbed up to 30% vs. 5% in plant non heme sources), using vitamin C containing foods with iron containing foods or sprouting grains to prevent phytate induced reduction in absorption help much(Somer)? Most sources are recommending 30mg of supplemental iron from prenatal supplements in pregnancy (Zimmerman, Somer). But there is some doubt as to weather women who are not iron deficient with anemia get any benefit from supplemental iron in pregnancy and it may increase blood viscosity and reduce placental blood flow or cause other problems of iron toxicity in the fetus (Scholl). Elevated iron stores for pregnancy are correlated with preterm delivery, preeclampsia and gestational diabetes and increased oxidative stress/free radical damage to tissues (Scholl). Thus it may not be wise to supplement with extra iron across the board in pregnant women. It is clear that iron needs increase during pregnancy, and many women’s diets do fall short of meeting their increased needs, but perhaps it would be wiser to get the increased iron needs from dietary sources, unless low ferritin levels or anemia are present. Bothwell claims that even in an iron rich diet with meat absorption is only about 5 mg per day, and iron needs in the last trimester are closer to 10mg per day, and thus it is impossible to get enough iron from the diet during at least the last trimester (Bothwell).

So what is a pregnant woman to do? Eat plenty of iron rich foods, preferably of the heme variety found in animal foods, especially red meats, eat iron containing foods with vitamin C which enhances iron absorption, and consider modest supplementation during late pregnancy when stores may become depleted. If a woman is vegetarian and not consuming iron from highly bioavailable sources, iron supplementation may be more important. Choosing iron supplements wisely is of great importance to prevent possible side effects like nausea or constipation. Food based iron supplements like Floradix, Mega Food Blood Builder or desiccated liver are best. Most prenatal multivitamins also contain 25-40mg of iron, should a woman choose to use them.

Iron Content of Foods:

2 tbsp Molasses 1.89 mg

1 c cooked Spinach 6.4 mg

4 oz beef Liver 6.9 mg

3 oz Hamburger 2.1mg

1 c Kidney beans, canned 3mg

(USDA Nutrient Database)

1 c oysters 16.6mg

1 c chard, cooked 4 mg

(Somer)

ZINC

Zinc is vital to reproductive health in general for both men and women and is essential for successful conception and maintaining pregnancy (Somer). Zinc also prevents birth defects like neural tube defects, premature delivery, fetal weight gain, and the development of fetal immune system, bone, vision and taste (Somer). Zinc also plays an important role in the production of insulin, prostaglandins and immune function in the mother. Zinc needs are 50% greater during pregnancy and considering many women’s diets are already deficient, special attention should be paid to getting adequate zinc in the diet (Zimmerman). The RDA for zinc in pregnancy is a scanty 11 mg, and there is no Upper Tolerable intake value for zinc currently (Sizer). Total zinc needs throughout pregnancy are close to 100mg, and pregnant women must absorb 2.6 mg per day to meet that need (Swanson). Dietary zinc has about a 25% absorption rate and would require at a minimum 10.5 mg per day to absorb the necessary 2.6 mg (Swanson). If absorption rates are lower, then intakes should fall in the 20-30mg per day range. Recommendations for total zinc intake from supplements and dietary intake ranges anywhere from 15-40mg. Many prenatal supplements contain 30 mg. A daily intake of 30 mg should be easily accomplished with a whole foods diet rich in seafood, animal protein, and legumes. I recommend pregnant women consider eating a serving of cooked oysters at least once a week. Vegetarian women should supplement with zinc in their prenatal multi to ensure adequate intake.

Sources of Zinc include:

3 oz Oysters 74mg

4 oz hamburger patty 7mg

1 c kidney beans 4.2 mg

(USDA Nutrient Database)

B VITAMINS

All of the B vitamins are necessary during pregnancy. B vitamins, along with magnesium are some of the biggest players in cell metabolism and energy production at a cell level. This is clearly important in helping a pregnant woman maintain her own energy levels and cellular processes, but perhaps even more vital for the growing fetus which is constantly building and growing cells which will use those vitamins to produce energy for the fetus to continue growing.

RDA and AI recommendations for B vitamins in pregnancy are as follows:

Thiamin- B1 1.4 mg

Riboflavin- B2 1.4 mg

Niacin- B3 18 mg

Biotin- 30mcg

Pantothenic acid- B5 6 mg

B6 1.9mg

B12 2.6mcg

Choline 450mg

(Sizer)

Dietary plus supplement intake on B vitamins is slightly higher, especially for biotin (75-150mcg), B5 (5-10 mg), B6 (2.5-5 mg) and B12 (3-5mcg)(Zimmerman). I would be willing to wager that these estimates are very conservative. Clearly we do not want pregnant women taking mega doses of B vitamins to prevent her unborn child from becoming accustomed to and habituated to higher doses of certain vitamins which will affect the child later in life (Kahl). But B vitamins are extremely important in cell development and the development of the nervous system of the fetus, and for the mother’s own endogenous hormone and energy production. Most prenatal vitamins I’ve looked at contain larger amounts of all of the B vitamins, especially B6 and B12. Since the B vitamins are water soluble, and easily excreted from the body, and a pregnant woman’s body demands are higher, she needs about 50% more than a non-pregnant woman (Zimmerman).

Fetal blood has two to five times higher concentrations of B6 in the blood than the mothers blood, this creates a fetal “drain” and can deplete the pregnant woman significantly in the second and third trimester (Zimmerman) B6 is particularly important in building proteins, hormones, enzymes, neurotransmitters, red blood cells and nerve and brain tissue in the fetus (Somer). A woman without enough B6 might have trouble maintaining proper hormone balance to support and maintain a pregnancy, or experience fatigue or other signs of B6 deficiency.

B12, though only needed in small amounts is extremely important in brain, nerve and blood cell development in the fetus (Somer). A mother low on B12 might also show signs of anemia (as B12 is a cofactor for iron absorption and utilization (Somer).

Choline, considered an essential nutrient, is used extensively in the development of the fetal brain and the neurotransmitter acetylcholine and the neurons which respond to acetylcholine in the 2nd trimester of pregnancy until about 3 months postpartum (Masterjohn). The RDA for choline in pregnant women is 450 mg, but some studies have shown that two to three times this amount can be extremely beneficial for the developing child (Masterjohn). Choline is found in liver, egg yolks, grass-fed raw milk (Masterjohn).

FOLIC ACID

Along with Iron, Folic acid or folate is one of the most commonly supplemented vitamins during pregnancy. Because of its importance in preventing birth defects, especially neural tube defects like spina bifida, the RDA urges all women of childbearing age to get at least 400mcg per day, and once pregnant to get 600mcg (Sizer). The Tolerable Upper Limit is set at 1000 mcg during pregnancy (Sizer). Women with a history of birth defects may be urged to take as much as 4 mg (4000mcg) (Somer). In addition to preventing grave birth defects, folic acid is used in normal cell division, building red blood cells, and improving birth weight (Somer). In addition folate plays a central role in nucleic acid synthesis in dividing and growing cells of the fetus, and decreases risk for preterm delivery and fetal growth retardation (Scholl). Folate is a cofactor along with Iron and B-12 to prevent anemia in pregnant women (Zimmerman). Folate (in addition to B-12 and B-6) is also a key player in reducing homocysteine, which is associated with placental abruption and preeclampsia in pregnancy (Scholl). Needless to say, any woman should ensure that she has enough folate in her diet or from supplements. Folate is of primary importance in the very first weeks of pregnancy, often even before a woman knows she is pregnant, thus the recommendation that ALL women of childbearing age get enough folic acid from supplements and diet (Somer). If folate status is low in the first few weeks of pregnancy, irreparable damage can occur, before anyone knows any better.

Folate is thought be to difficult to get from dietary sources in the quantities necessary for healthy pregnancy, but many processed foods are fortified with folic acid, and all multivitamins for women, especially prenatal vitamins will contain at least 400mcg of folic acid. Some studies have shown that only supplements will raise blood levels of folate adequately (Somer). But is it possible to get adequate amounts of folate from dietary sources alone? Surely Paleolithic women weren’t taking sublingual folic acid supplements? At least a fair number of their babies were born healthy; otherwise humans wouldn’t still be around. Folate absorption is dependent on zinc status, so a woman must ensure she is also getting enough zinc from her diet in the form of animal protein, legumes or supplements (Masterjohn). Folic Acid, the form most commonly found in supplements and fortified foods is not the form used in the body, or found in food sources as folate, the body must convert folic acid in to folate before it will cross the placenta (Masterjohn). But folic acid supplements are still shown to improve folate status, so should strongly be considered (Somer). If a woman is eating a whole foods diet, which will be significantly lacking in fortified foods, which foods should she look to for folate? Leafy greens, green vegetables, legumes, meats, eggs and nuts/seeds all contain folate. The daily requirement of 600 mcg of folate can be met by eating any of these foods below.

3.7 oz chicken liver

3-6 oz calf liver

1.7 c lentils

2-3 c legumes

2.3 c spinach

3-6 c leafy greens

2.3 c asparagus

(Masterjohn)

In addition 1 cup of mushrooms provides about 23 mcg of folate, so regular use of mushrooms for three months prior to pregnancy can also benefit folate status (Kahl, USDA Nutrient Database). A diet containing plenty of leafy greens, legumes, and animal protein sources should be able to supply a pregnant woman with plenty of folate, and zinc.

VITAMIN A

Vitamin A is perhaps the most controversial of all the nutrients in pregnancy. It is absolutely a required nutrient in pregnancy, and adequate vitamin A helps to prevent birth defects including neonatal mortality, growth retardation, sterility and cardiovascular malformations (Azais-Braesco). Vitamin A is used in many basic physiological processes of growth, reproduction, immunity and epithelial tissue maintenance, and is absolutely critical during periods when cells are actively proliferating and differentiating, as in pregnancy (Azais-Braesco). Vitamin A is essential to the development of the fetal immune system, vision, and proper cell division and growth (Somer).

On the other hand high doses of vitamin A have been associated with teratogenic events, birth defects, and hypervitaminosis A, essentially vitamin A toxicity. This is a concern especially in pregnancy when the health of the future child is at stake (Azais-Braesco). The question remains as to what is a safe level of vitamin A intake during pregnancy, which both confers the benefits and prevents complications from overdose? Very few studies have been done on humans other than epidemiological studies, due to the ethical concerns of the potential risks in giving high doses of vitamin A in pregnancy (Azais-Braesco). In fact, most of the information we have on vitamin A levels and toxicity is from animal studies, which may or may not be directly applicable to toxicity in humans (Azais-Braesco).

The RDA for vitamin A in pregnancy is 2600 I.U.(Masterjohn). The WHO recommends that pregnant women get no more than 10,000 i.u. (retinol from animal sources) in one day, and no more than 25,000 as a weekly dose (Azais-Braesco). It is interesting to note that no teratogenic events have been associated with beta carotene consumption, and it seems to have a similar protective effect as retinol, the animal form of vitamin A (Azais-Braesco). But the recommendations for how much vitamin A a woman should actually consume in pregnancy vary. One source suggests 4000 i.u as a daily recommendation (Somer). Another suggests 2500 I.U., which is below the RDA (Zimmerman). Yet another source recommends 20,000 I.U from food sources (Masterjohn). Hence the controversy, the most widespread recommendation is not go over 10,000 I.U. from both dietary and supplemental sources. Most studies showing toxicity or teratogenic events (done on rats) are based on single incidence of an extremely high dose of vitamin A, whereas most of the epidemiological studies on humans are based on moderate doses of vitamin A from food sources which do not result in birth defects (Azais-Braesco). This indicates that perhaps food sources of vitamin A are significantly safer than supplements of pre-formed vitamin A in pregnancy. This is a natural expectation, since, as always, Mother Nature knows best, and the body knows what to do with food sources of vitamins and minerals. This isn’t to say that a woman couldn’t overdose of vitamin A from food sources, it is possible physiologically, but actual occurrences seem to be rare (Azais-Braesco).

The Weston Price Foundation recommends 20,000 I.U. from cod liver oil, milk, eggs, and butter, and up to 8 oz of liver per week (Masterjohn). They claim that there was one flawed study that suggests more than 10,000 I.U. is considered dangerous, and that many other studies have shown that intakes from food between 20,000 to 40,000 I.U. were safe, and in fact reduced the likelihood of birth defects (Masterjohn). While the Weston Price Foundation is often considered extremist by modern people, they are in fact suggesting and supporting diets that are closer to what our ancestors ate and remained healthy on, including during pregnancy. Weston Price’s work on nutrition in traditional peoples was a landmark in the study of nutrition, and I see no reason to throw out the suggestion of 20,000 I.U. from food sources as hogwash.

But, alas, what is safe for women in pregnancy? What did paleo moms consume during their pregnancies? Did their babies suffer from birth defects by women unknowingly consuming too much liver or fish oil? Knowing that vitamin A is defiantly an important nutrient in pregnancy and fetal development, my suggestions are as follows. 1)A woman in her reproductive years should ensure that her vitamin A status is good, long before pregnancy occurs. If a woman has good vitamin A status, and all the vitamin A needed during pregnancy for the fetus was drawn from maternal stores, they would only be depleted by 10% (Zimmerman). Ensuring proper nutrition prior to pregnancy will ensure healthy vitamin A levels for most of the pregnancy. 2) Vitamin A during pregnancy should come from food sources, not supplements. This includes natural cod liver oil, liver (3-8 oz per week), animal meat, eggs, milk, butter and beta-carotene containing vegetables like carrots, sweet potatoes and leafy greens (Masterjohn, Zimmerman). 3)Vitamin A consumption should fall somewhere between 5000-15000 I.U. per day. Food sources of vitamin A are listed below.

3 tsp Cod Liver Oil 4500 I.U.

3.5 oz liver, chicken 14,378 I.U

2 oz liver, beef 14609 I.U.

8 oz whole milk, cow 102 I.U.

1 carrot, large 12028 I.U. from beta carotene

(USDA Nutrient Database)

VITAMIN D

Vitamin D is a nutrient of much contention lately. Long touted as a toxic, fat soluble vitamin, studies are now showing otherwise, that it is safe in quantities up to 10,000 i.u. on a daily basis, and extremely beneficial in addressing many modern ills, including cancer, diabetes, cardiovascular disease, inflammation and osteoporosis. Vitamin D is definitely a vital nutrient in pregnancy both for mother and fetus. Vitamin D is primarily used to help develop and strengthen fetal bones and maintain bone integrity of the pregnant mother (Somer). Studies have also shown that Vitamin D deficiency in pregnancy can lead to impaired cardiac development and poor nerve and brain development in the fetus (Hollis). A newborn must have adequate stores of vitamin D from the mother at birth (or spend time in the sun with mom) to prevent tetany, convulsions and heart failure (Masterjohn) Currently the RDA for vitamin D in pregnancy is a meager 400 i.u. per day.

While considering optimal levels of Vitamin D in pregnancy I want consider first the fact that in Paleolithic people the primary source of vitamin D was skin exposure to the sun. A Caucasian with full body sun exposure can make anywhere between 10,000-50,000 i.u. within a matter of half an hour (Hollis). If the body can produce these levels of vitamin D naturally when exposed to sunlight, one could make the assumption that it is both safe and important for us to be getting close to that amount on a regular basis. Pregnant paleo moms were probably outside in the sun all day, gathering food, walking around or just enjoying themselves, and later on, the paleo babies and moms were hanging out outdoors while breastfeeding or walking around. People made enough vitamin D just out of lifestyle circumstances. Today, especially in America, in northern latitudes with long winters, 9-5 desk jobs and sunscreen, we just aren’t getting outside to make vitamin D from sun exposure. Women with darker skin are at an even greater disadvantage as it takes longer for their skin exposed to sunlight to make endogenous vitamin D (Hollis). So what does a pregnant woman who can’t get outside for 6 hrs a day in the winter to do to ensure she is getting enough vitamin D both to protect her own bone and immune health, and that of her growing baby? The answer lies somewhere between food and supplementation. There are many traditional foods that contain food sources of vitamin D that are safe and beneficial for pregnant women, and the safety of Vitamin D supplements allows pregnant women to use supplemental vitamin D safely as well.

Studies in pregnant women which measured vitamin D status found that doses of greater than 1000 i.u per day were required to bring deficient blood levels up to normal (Hollis). A woman who does not supplement with D or spend time in the sun will deplete her vitamin D stores in her third trimester, during the time in which final bone mineralization is occurring in the fetus (Masterjohn). Vitamin D status of the infant is directly dependent on the vitamin D status of the mother during pregnancy, and a woman who is deficient will birth a baby who is deficient in vitamin D, which is compounded by vitamin D deficient breast milk (Hollis). Studies in which pregnant women are supplemented with 2000-4000 i.u. per day bring blood levels of vitamin D up to a healthy level during pregnancy, with no detrimental effects on the infant, while supplementing with the RDA of 400 i.u. does not change blood levels of vitamin D (Hollis).

Based on this information a pregnant mother may feel confident that supplementing with 4000 i.u. of vitamin D (cholecalciferol) is a good move during pregnancy if she can’t manage to spend 30 minutes outside in the sunshine. But rather than buying a pill, a woman can rely on some traditional foods to supply her with enough vitamin D. The Weston Price Foundation recommends 4000 i.u. per day from cod liver oil and other foods rich in vitamin D (Masterjohn) Cod liver oil, long used as a safe food supplement for both mothers and infants, is an excellent source of EFA’s like DHA and vitamin D. Studies have shown that pregnant women using cod liver oil have babies with a lower risk of having type 1 diabetes (Sullivan). Today there are cod liver oils for sale with 1000 i.u. of vitamin D per tsp. 2-3 teaspoons of this oil can supply vitamin D in sufficient quantity for a pregnant woman, along with DHA, EPA and Vitamin A. Vitamin D is also found in significant quantities in liver, oily fish, eggs and milk (usually fortified), and these foods should be included in the diet regularly. But as always, Mother Nature knows best, and spending time walking outside in the sunshine and fresh air with large areas of skin exposed to the sun everyday for 20 minutes to an hour is the best way to get your vitamin D.

VITAMIN C

The RDA for vitamin C in pregnancy is a scanty 85mg, while the Upper Tolerable intake is 2000mg (Sizer). Vitamin C is vital as a free radical scavenging antioxidant, for both mother and fetus and is used in the production of collagen (which makes up placental tissue, bones, teeth, connective tissue) and in immune function/host resistance and tissue healing (Somer). High levels of vitamin C have been used as a “natural” abortion technique, supposedly making the uterus inhospitable for the developing ovum and preventing attachment to the uterine wall. Though this is rarely successful, is it important to note that excessive amounts of vitamin C may be detrimental to the health of the fetus. High doses of vitamin C, like magnesium, can cause diarrhea and peristalsis which may pose a danger of stimulating uterine contractions. That said, a pregnant woman should strive to get plenty of vitamin C from her food in the form of fresh fruits and vegetables. Leafy greens and brightly colored fruits like tomatoes, bell peppers, berries and even liver provide ample amounts of vitamin C (Somer). There shouldn’t be a reason to use larger amounts of vitamin C from supplements as long as a woman is eating a whole foods diet rich in vitamin C and other antioxidants.

Nutrient Dense Super Foods for Pregnancy

As stated before a woman during pregnancy should focus less on the quantity of food she consumes and more on the quality and nutrient denseness of the foods she chooses. Here is a list of foods that are particularly nutrient dense and beneficial for one reason or another during pregnancy.

Cod Liver Oil –EFA’s, Vitamin D, Vitamin A

Milk (if tolerated) – rich in fat soluble vitamins, protein, calcium

Butter- rich in fat soluble vitamins

Free range Eggs, with yolks- quick protein, rich in lecithin and choline for brain development

After all the discussion of the nutrients needed during pregnancy, the question remains, is it a good idea to use supplements during pregnancy? As I’ve said before, Mother Nature knows best, and whole foods are truly the best source of nutrition for any body, pregnant or not, but due to the decreasing nutrition of our commercially grown foods, limitations on time, and the fact that we are human after all, and probably won’t be able to eat a perfect diet 100% of the time, sometimes supplements are beneficial in pregnancy. A broad spectrum prenatal multivitamin will give a little extra insurance that you and your growing baby are getting the nutrients you need (Somer). But you shouldn’t rely on a multivitamin to get everything you need. Morning sickness, poor digestion, or other complications could make multivitamins poor absorbed during pregnancy, so you should always focus on eating a nutrient rich diet.

The single supplements that every pregnant woman should strongly consider are Folic Acid (800mcg), Iron (18-30mg), Omega 3(4-6g), Calcium (1000mg), and Magnesium (600mg). Most of those are available in a high quality prenatal multivitamin, except for the Omega 3, which should be taken as fish oil, either liquid or in capsules. A whole food, nutrient rich diet should ensure that you get everything else you need.

What would a daily diet look like?

Based on all of the above recommendations what would a good daily diet look like?

These quantities more than fulfill the daily requirements for multiple nutrients required for pregnancy. A general rule of thumb for the daily diet in pregnancy is 2-3 calcium rich foods, 8-10 servings of vegetables, 1-3 servings of fruits, 2-3 servings of whole grains, 3-5 servings of protein, 2-4 servings of low mercury fish per week, and 64 oz of water per day (Kahl).

Nutrients are the building blocks of our bodies, and the functions our bodies perform day in and day out, and it is no different when building a new life. All the nutrients in the human diet are needed at the right time in the right quantity for development of the fetus to go smoothly. A lack of any one nutrient at a specific time might very well lead to a malformation, abnormality or risk for disease later in life. There are known as critical periods (Kahl). The first few weeks of pregnancy, from conception to week 3 or 4, often before a woman knows she is pregnant is when folic acid is most critical in preventing birth defects (Scholl). This is why all women of childbearing age are encouraged to get plenty of folic acid in the diet and through supplements, but this can be extended to all nutrients. A woman should be well nourished before pregnancy occurs to ensure that her fetus has all the nutrients available when required. A deficiency of any sort in the mother could possibly affect her unborn child. But with that said, the human body has an innate intelligence and know how, and a mother’s physiology will adjust and increase absorption or mobilization of certain nutrients in the body to provide for the growing fetus. This is why it is so very important to ensure a proper, nourishing diet before, during and after pregnancy. Food is our best source of nutrition, even though multivitamins and cod liver oil supplements are nice to have, and even necessary in many cases, a woman should never rely on just her supplements to provide the necessary nutrients, fuel and nourishment for her own body or that of her unborn child. Food first, and nourishing, whole food is best. Despite all the discussion, I still find that the best advice for women in pregnancy is to eat a wide variety of whole foods, and include special nutrient rich foods in their diet to increase the nutrient content during this miraculous time of life we call pregnancy, and motherhood.

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